NCQA: Patient-Centered Medical Home No Longer “Unduly Onerous”

The NCQA patient-centered medical home (PCMH) has gotten a makeover to reduce documentation burdens, lower costs, and facilitate quality improvements.

May 10, 2017 - In addition to being dedicated, hard-working, and compassionate, physicians tend to share the character trait of being a very vocal, forthright, and outspoken group of professionals.

Over the past few years, they have had ample opportunity to exercise these qualities in response to an avalanche of changes to their profession. EHR adoption, meaningful use, MACRA, the Affordable Care Act, value-based reimbursement, and even the patient-centered medical home (PCMH) have all ruffled plenty of feathers in the physician community.

Overwhelmed by mounting reporting requirements, changing workflows, new technologies, and uncertain reimbursements, physicians have been clamoring for rule makers and policy experts to relieve the pressure.

The NCQA is among a growing number of industry leadership organizations heeding those cries – and making a concerted effort to respond to them.

The organization recently announced a comprehensive overhaul of the patient-centered medical home recognition program for primary care providers that reduces the paperwork and modernizes the attestation process. Similar changes will soon take effect for specialists.

Michael Barr, MD, Executive VP of the Quality Measurement and Research Group at NCQASource: Xtelligent Media

The changes aim to create a much more user-friendly version of the popular practice transformation framework that avoids the pain points of previous iterations of the program, said Michael S. Barr, MD, Executive Vice President of the Quality Measurement and Research Group at NCQA.

“We have heard from providers that the recognition process has been unduly onerous, and that the documentation processes weren’t exactly relevant to improving care,” Barr acknowledged. “We wanted to change that.”

“Without watering it down, we’ve tried to make the recognition process considerably easier, friendlier, and more customizable. We wanted to reduce or eliminate as many costs as we can control from our end, lower the documentation burdens, and streamline some of the aspects of the recognition process that were taking people away from patient care.”

The new guidelines accomplish all of those goals and more, Barr said, by realigning the standards to take a more modern approach to demonstrating improvement. Perhaps the most striking change is the abolition of distinctions between Level 1, 2, and 3 that have characterized the program thus far.

“Now, either you are recognized or you’re working towards recognition,” he explained. “We decided to eliminate the idea of levels. We have instead set the recognition threshold somewhere around what used to be Level 3. That will help providers move away from the check-box mentality and towards the idea that they are on a continuum of improvement.”

“The healthcare industry has moved away from that kind of all-or-nothing measurement, and we agree that it is no longer the most effective way to encourage improvement.”

NCQA has also replaced the three-year recertification cycle with annual check-ins that don’t require providers to go through the entire recognition process again and again. The yearly meetings will help to ensure that recognized practices are maintaining a high level of patient-centered care and working towards continuous improvement.

Practices hoping to achieve their initial PCMH recognition will also find the process somewhat changed.

“Instead of having a one-shot submission that is basically a black box, we are implementing more collaborative and transparent check-ins, as well as an online reporting platform,” Barr said.

“Every practice will be assigned an NCQA representative – a real person – who will help them move through the process. They won’t be a consultant. They won’t help the practice do the work they need to do, but they will provide a lot more support than if the practice just downloaded the standards and went off on their own.”

The average primary care practice may take between ten months and a year to transform into a PCMH, during which time will need to meet 40 core criteria and 25 elective criteria from the NCQA’s broad new menu of options.

During the process, they will schedule regular meetings with their dedicated representative from the NCQA.

“The practice gets to decide what they are going to prepare for each of their check-ins,” Barr said. “The reviewer will get on the phone with the practice representative and go over the information submitted up to that point. They can upload documents or demonstrate a particular process through a screen share.”

“Instead of taking screenshots of each part of the process, they can do a live demo for the representative through a screen share. Here’s the schedule; here’s how we handle requests; here’s how we generate the reports. The representative can get a much, much better idea of how well that process is working, and they can very easily say, ‘Yep, you’re doing great and I’m going to give you credit for this.’”

If the representative doesn’t believe that the practice has met the requirements for a particular task, the provider doesn’t have to go back to square one. They can simply make changes and demonstrate their fixes at the next scheduled meeting.

“They don’t have to reapply for anything or lose any time,” Barr explained. “This iterative, interactive process is geared towards making sure that the practice knows more about what they have to do while giving them a more flexible way to do it. It doesn’t leave as much to the imagination, and it helps to avoid misinterpretation.”

Potential PCMHs may find another thing to like about the updated guidelines: an option that allows practices to attest to the NCQA using the same electronic clinical quality measures (eCQMs) they’re already collecting for MACRA or the Comprehensive Primary Care Plus (CPC+) program.

“There are 35 eCQMs embedded in CPC+ that are also among the measures for the Merit-Based Incentive Payment System (MIPS),” noted Barr. “We’re not changing them in any way for this purpose. The exact same measures they are already reporting, in exactly the same way, will help them achieve PCMH recognition. We think that will significantly streamline the process and make it easier for practices to engage with us.”

In addition to allowing providers to take a more flexible and less convoluted approach to achieving recognition, the new recognition process attempts to address one of providers’ most pressing concerns: the unpredictable and worrying costs often attributed to the PCMH process.

A recent spate of industry reports may have spooked potential PCMH practices with assertions that the transformation costs could average around $150,000 a year, and that upkeep of staffing and care coordination requirements may shake out to $8600 per month.

Barr does not deny that practice transformation requires an investment of both time and capital.

“If a provider wants to practice to PCMH standards and they are starting from a point that is far away from the goal, then there are going to be costs associated with that,” he stated. “Sometimes practices do need to add a nurse care coordinator or other staff member to support these enhanced functions. The NCQA can’t do much to change that for practices that don’t have those processes and people in place.”

But he cautions against taking the alarming figures included in industry assessments at face value.

“Some of the literature related to PCMH costs can be a little bit misleading,” he said. “Yes, you might have to hire a new person, but the person who was doing that job before is now free to do something else, or work more efficiently.”

“That new nurse or care coordinator might save you thousands of dollars a month by reducing unnecessary appointments that are now open to let you bring in new patients, for example. And that might actually save you money even though you are laying out for a salary. So some of the costs aren’t true costs when you really examine the practice’s income and outlay.”

He added that some of the studies often cited by PCMH naysayers also included the costs of electronic health record (EHR) adoption, despite the fact that practices have had a multitude of reasons to purchase and implement health IT.

“It is certainly important to have an EHR in order to be recognized as a PCMH, but chances are you need that EHR anyway to meet the regulatory requirements of meaningful use or MACRA,” he pointed out. “So it’s not a PCMH cost, exactly, and it may not be fair to position it that way.”

Barr also defended the PCMH against another set of reports that have painted the model as unable to produce improvements in care quality, clinician efficiency, or patient satisfaction.

The processes takes too long while delivering scant results, argued RAND Corporation after an examination of a three-year federal demonstration project. A poll from The Commonwealth Fund and Kaiser Family Foundation found that more than half of physicians felts the administrative and reporting requirements involved in PCMH recognition were detracting from quality care.

Yet this data, too, must be taken with a grain of salt, said Barr.

“We understand that there were some studies a few years ago that didn’t find much difference between a recognized practice and other practices,” he said. “But again, I believe they were hampered by the fact that they looked at practices while they were still in transition, and those operating under previous iterations of the program.”

“Naturally, if you compare Level 1 and Level 2 practices using the early versions of the program to non-PCMH practices, you might not see much of a difference in performance or cost savings.”

“This is something that takes time to implement and mature and anchor into the daily operations of a practice. Patience isn’t always easy when it comes to the financials of healthcare, but we’ve been doing this since 2008 and our experience has shown that patience does actually pay off.”

Some primary care providers may feel as if they do not have the luxury to be patient in a regulatory and reimbursement environment that is finding new ways to squeeze them every day. Barr hopes the revamped PCMH recognition process will help providers move towards a more efficient, effective way to deliver care, but they will need more than yearly check-ins to succeed in an increasingly data-driven world.

“It’s time to optimize EHRs so that we can really align them with what we need to do to improve patient care,” he urged stakeholders.

“Practices that adopt the PCMH and specialty practice recognition that already have EHRs in place should focus on optimizing their tools to create the best possible systems they can for individualized patient care. That means adding clinical decision support and longitudinal care plans and not just doing checkboxes.”

EHRs should be redesigned to effective tell the patient’s story, he said, and equip providers across the care continuum with the data they need to make informed, personalized, and effective choices with the patient and her caregivers.

“A patient record should be actually useful to those who need it in any healthcare setting,” said Barr. “EHRs should help clinicians identify the questions that they should be asking and be able to improve the clinician’s understanding of what that patient needs, what has been accomplished, and who is involved. That way everyone who receives the record is working from the same set of data and can collaborate effectively.”

“Practices need the underlying technical infrastructure that can truly support them in their journey towards becoming a medical home. We think we’ve made it a lot easier to get there from our end, but their health IT use is also a major factor in whether or not they can successfully improve quality and outcomes.”